H. Is There a
Prohibition of Choosing a Disabled Child Once IVF Is Being Performed?

I. Where
Is the Line?

J. Halachic
and Hashkafic Justifications for Avoiding Disabilities

K. Choosing Infertility
over Possible Disability

L. A
Last Dilemma: Infertility versus Disability

M. The Conundrum of
Non-Existence

N. Limitations on the
Ability to Choose

Improving Our Children

The first modern step toward influencing
the creation of children with desirable traits was the field of eugenics, which
proposed that the human species could be improved if those individuals with
“desirable” traits were encouraged (or permitted to the exclusion of others
with less desirable traits) to reproduce. In the first third of the 20th
century, eugenics programs were robustly pursued throughout the world,
including the United States.[1] After
the Second World War, most of the world lost interest in eugenics, but eugenics
groups still exist to this day. Nevertheless, eugenics has always been a rather
hit-or-miss prospect, unable to accurately predict or control the outcome of
childbearing.

With the advent of in vitro fertilization
(IVF) and preimplantation genetic diagnosis (PGD), the ability to choose the
genetic characteristics of a baby became a reality. Not even the genetic
qualities of the parents were a barrier to choosing “good” genes for a child,
exemplified by the development of “genius” sperm banks such as the Repository for Germinal Choice, colloquially known as the Nobel
Prize sperm bank. Further advances in genetics currently in development may
allow parents to genetically engineer their children and select any genetic
traits that they wish from a genetic menu.

The idea of designer babies has raised
a myriad of ethical questions. While most people probably accept the use of
genetic engineering to correct genetic defects that cause incapacitating or
deadly diseases, many people draw the line at choosing more peripheral
characteristics, such as eye or hair color. Nevertheless, while it is likely
that the more obvious cases will garner a consensus (such as favoring repairing
the gene for Tay-Sachs and eschewing manipulating genes for minor cosmetic
issues), there are traits which will remain contentious. Where will the ability
to select for athletic ability or intelligence fit into an equation that
balances valid medical advances with frivolous manipulation of our genomes?
Even before society has come to terms with the basic question of which traits
are legitimate to actively pursue, a new and unexpected issue has arisen.

An Unexpected Turn

Until recently, discussions about what parents desire for their
children, whether in the area of education or genetics, assumed that parents
wanted the “best” for their children. For instance, it has long been axiomatic
that parents pray that their children will be healthy. Secondarily, parents
hope for desirable physical and personality traits and go to great lengths to
obtain both. But what if objective observers would find the trait considered “desirable”
by the parents to be clearly undesirable to the child – particularly, what if
parents did not want “healthy” children?

In late 2006, the on-line edition of the
medical journal Fertility
and Sterility published
the results of a survey of United States fertility clinics. As part of the
study’s inquiry into the practice of pre-implantation genetic diagnosis, labs
were asked whether they had provided help to families seeking to select an
embryo for the presence of a disability:

The publication of the survey caused a
small media sensation, as demonstrated by an Associated Press article
describing the journal findings:

The power to create
“perfect” designer babies looms over the world of prenatal testing. But what if
doctors started doing the opposite? Creating made-to-order babies with genetic
defects would seem to be an ethical minefield, but to some parents with
disabilities – say, deafness or dwarfism – it just means making babies like them. And a recent survey of U.S. clinics that offer embryo screening suggests it’s already happening. Three percent, or
four clinics surveyed, said they have provided the costly, complicated procedure
to help families create children with a disability. . . . But the survey also
has led to a debate about the definition of “normal” and inspires a glimpse
into deaf and dwarf cultures where many people do not consider themselves
disabled.[3]

Despite the shocked reaction of many observers, there
was not universal condemnation of this practice. As media accounts reported,
some people with inherited disabilities, particularly dwarves, have publicly
questioned why they should not be permitted purposefully to create offspring
like themselves. They question the criteria used to decide what is “best” for a
child and argued that other considerations, such as the child fitting into the
family and increased parental convenience in raising the child, should also
play a role.

In a recent essay in the Hastings
Center Report entitled “The Ashley Treatment: Best Interests, Convenience,
and Parental Decision-Making,” the authors discuss the difficulty of
distinguishing the needs of a disabled child from the convenience of their
parents. The essay deals with the case of a nine year old girl with static
encephalopathy, whose parents subjected her to “growth-attenuated” treatment
when she was six years old.[4] In an
act later widely condemned by advocates for the disabled as demonstrating
fundamental disregard for the dignity of a helpless child, Seattle Children’s
Hospital, with the consent of its ethics committee,

devised what [it] called the “Ashley Treatment,” which included
high-dose estrogen therapy to stunt Ashley’s growth, the removal of her uterus
via hysterectomy to prevent menstrual discomfort, and the removal of her breast
buds to limit the growth of her breasts. . . .

According to her parents, keeping Ashley small – at
around 75 pounds and four feet, five inches tall – means that Ashley can be
moved considerably more often, held in their arms, be taken “on trips more
frequently,” “have more exposure to activities and social gatherings,” and
“continue to fit in and be bathed in a standard-size bathtub.” All this serves
Ashley’s health and well being, so the parents argue, “the increase in Ashley’s
movement results in better circulation, GI functioning (including digestion,
passing gas), stretching, and motion of her joints,” which means that Ashley
will be less prone to infections.

Undoubtedly, the
parents are right that Ashley will benefit in the manner they have proposed if
they can do all these things for her. The claim about the value of small size
in a particular social circumstance is certainly not unique. Dwarves have given
the same argument as a justification for preferring to have short children.
They have argued that parenting dwarves is desirable for them because of their
own size and because they have made modifications to their homes and their surroundings
to take into account their short stature.[5]

While acknowledging the possible
benefits that might accrue to Ashley, the authors point out that the parents
may well have had other motives besides the exclusive benefit of their
daughter, not least of which would be their own convenience. However, equating
the cases of Ashley’s parents with dwarf couples who desire to raise dwarf
children obscures an important distinction. Regardless of how one balances the
issues, there is an inherent and very important distinction between the case of
Ashley and the deliberate creation of a child with a disability similar to its
parents. Namely, Ashley will always be dependent on her parents, while a normal
stature child born to dwarves is only dependent for the early portion of its
life. While Ashley’s parents arguably are not depriving their daughter of any
future opportunities, the parents who choose to create a child who is deaf or a
dwarf most certainly are.

C. Do We Really Want the Best for Our Children?

But is it a given that parents must
always do what is best for their children? We do not expect parents always to
take the course that maximizes opportunities and benefits for their children.
Most parents who undergo assisted reproduction for infertility purposes are
content with a “normal” child and do not attempt to improve upon the randomly
produced outcome, perhaps seeking only to steer clear of avoidable diseases.
The challenging question is when does a given genetic or congenital trait cross
the line from being a “normal variant” to being “abnormal?” Is “normal” in the
eye of the beholder, or is there an objective standard that can be applied to
questions of assisted reproduction to evaluate such situations? Additionally,
there may be differences between choosing to create a disabled child, passively
allowing the creation of such a child, and choosing not to influence what type
of child is born. The most difficult question arises when the choice is between
using assisted reproduction (when halachicallypermitted) to create a
disabled child and remaining childless.

A key component in formulating an
authentic Jewish approach to these questions must take into account parental
motivations. Despite halachic support for procreation
utilizing assisted reproduction, it is apparent from the Torah and everyday
experience that it is often the emotional desire for children that primarily
motivates married couples to utilize reproductive technologies, not only the
mitzva of procreation.[6]
As we shall see, were a couple unable to have children by any unassisted
method, most poskim allow (but do not require) IVF and consider the
offspring to have a status similar to a child conceived via normal means.[7] The fact many poskim permit
assisted reproduction when not required demonstrates that there is a
compassionate halachic approach to infertility which recognizes parenthood as
the fulfillment of a legitimate strong emotional need. If this is so, were
there to be no means of preventing the creation of a child with a significant
disability, there might be no compelling reason to forbid implantation of
pre-embryos with genetic abnormalities that will lead to even significant
potential disability, if the pregnancy is expected to lead to a viable child.

On
the other hand, one might still question whether it is appropriate to create a
child who will suffer if halacha does not require the procedure that will cause
the conception in the first place. Those poskim who permit IVF with PGD
for the prevention of severe genetic abnormalities are merely allowing a couple
who is not
infertile to avoid conceiving naturally in order to fulfill the mitzva of
procreation without the risk of a severe genetic defect.[8] Were the couple to be unable to have
a child naturally, it is possible that the poskim would rule that shev
v’al taaseh adif, that “it is better not to act (and create a disabled
child)” than to do the non-required procedure of performing IVF and PGD and
thereby creating a disabled child. We will evaluate the halachic factors
involved in assisted reproduction and the Jewish approach to disability to aid
in determining which approach is correct.

To begin, we must recognize that most
parents are satisfied with having average offspring. Presumably, they are
content with children of average intelligence, athletic ability and eyesight
because they themselves tend to be near the center of the bell curve. Simply
put, “normal” parents just want “normal” children like themselves. Presumably,
the current consensus against designing babies to be “artificially” smarter,
faster, and having better eyesight is because these are not traits that we
possess, and we therefore do not place sufficient value on them to outweigh our
fear of eugenics.

But if society does not place the
genetic perfection of its children as the highest ideal, why should it object
to those people who want to choose offspring that share their own limitations
or disabilities? As one woman with dwarfism commented in a public interview,
“You cannot tell me that I cannot have a child who’s going to look like me. . .
. It’s just unbelievably presumptuous and they’re playing G-d.”[9]

D. The New Reproductive Technologies

In reality, the ideal in Judaism is
for us to “play G-d.” We are instructed to emulate Hashem in all of our
activities, including the ability to make distinctions.[10]
In the havdala service performed at the end
of the Sabbath and festivals, we praise Hashem for distinguishing:
between Holy and mundane, between light and dark, between the Jews and the
other nations, and between the Sabbath and the weekdays. The Torah itself (Deuteronomy 30:15–19) clearly commands us to distinguish between good and
evil and to choose the good. It is the ability to make distinctions between
difficult cases that makes us humans in the image of Hashem. Judaism not only
finds it reasonable to make fine distinctions, it demands that we utilize that
ability to untangle complex ethical questions.

Just such nuanced
distinctions are necessary for correct evaluation of the multiple scenarios
that the new reproductive technologies present. While Judaism enthusiastically
embraces any technology that helps to further the mandate of healing the sick,
all medical interventions must take into account Jewish values and be performed
within the confines of halachic constraints. As Dr. Richard Grazi, director of the Division of Reproductive Endocrinology
and Infertility Healing at Maimonides Medical Center and noted expert on
the Jewish approach to infertility, writes, “Most people can quote the biblical
injunction to “be fruitful and multiply” (Genesis 1:28).
However, it is important to understand that this is not a command to be
actualized at all cost.”[11]
Sometimes we must demur when the ethical costs of assisted reproduction
outweigh the benefits. Additionally, there are societal concerns to be taken
into account. As Rabbi Prof. Avraham Steinberg, author of the Encyclopedia
of Jewish Medical Ethics asserts, “Obviously society should not be involved
in intimate and private decisions of couples, but when they come to the society
for help and for [assistance with] expenses it seems to me legitimate for
society to make limiting decisions.”[12]

Nevertheless, the poskim have
enunciated the rule that all technology, including assisted reproduction, must
be used within certain ethical parameters. IVF is almost never appropriate
except for a married couple, using only the couple’s egg and sperm.[15]
With respect to choosing the characteristics of offspring, the same issues
apply. The use of reproductive technologies is permitted so long as they do not
contravene any othermitzvot.

For example, Rabbi Shlomo Zalman
Auerbach rules that artificial insemination is permitted even if a couple
already has fulfilled the mitzva of
procreation with a boy and girl. However, Rabbi Auerbach explains that they may
not choose the sex of the baby by separating out the sperm containing the X or
Y chromosome since they will be actively destroying the unused remainder. This
is true even if by making such a selection, an additional mitzva will be observed, such as a childless couple
choosing a boy so that there might be a pidyon haben (redemption of the
firstborn son). On the other hand, if the mother is a carrier of an X-linked
disease, Rabbi Auerbach permits artificial insemination with female sex selection
if the couple so desires.[16] The
issue of discretionary gender selection once IVF is being performed for a valid
indication is a more complex question.[17]

E. In Vitro Fertilization to Avoid Disease

Conventionally, preimplantation genetic
diagnosis involves taking a cell from the 8 cell stage of an in vitro
fertilized pre-embryo and testing it for specific genetic defects. Only
pre-embryos free of genetic disease are implanted in the uterus of the woman.
Prof. Avraham Avraham, author of Nishmat Avraham, has reported that in
principle, both Rabbi Yosef Sholom Elyashiv and Rabbi Yehoshua Neuwirth have
granted permission for PGD to be performed for couples where both partners are
carriers of a defective recessive genetic trait or have a child that has such a
genetic abnormality.[18]

In particular, according to Rabbi Prof.
Avraham Steinberg, Rabbi Elyashiv has permitted PGD and destruction of affected
zygotes to prevent cases of Fragile-X and even in a case of a woman with
neurofibromatosis who only had skin lesions.[19]
Rabbi Dovid Feinstein has taken a similar view as to the permissibility of
discarding “extra” pre-embryos.[20]
We see that preimplantation genetic diagnosis is accepted by rabbinic
authorities when used to prevent serious diseases in offspring.

It is important to understand that in
vitro fertilization and preimplantation genetic diagnosis are permitted to
further the goals of procreation for those who are infertile and desire
children or to prevent disease in children. No such permission exists merely to
allow the parents to choose particular traits for their child. This is because
artificial insemination and in vitro fertilization involve potential Torah
prohibitions that are only waived for the sake of allowing infertile couples to
conceive or to avoid serious illness in the children.[21]

The capability of a couple to have unaffected
children naturally (and therefore the absence of a halachically sanctioned
purpose for IVF) is certainly a sufficient reason to disallow the use of the
new reproductive technologies to create ill children or to a priori
create disabled children. It is less obvious whether the same logic is
sufficient to bar the deliberate creation of disabled children as part of an
already existing IVF cycle, particularly when the parents argue that what
appears to be a disadvantage to outsiders is actually beneficial within a
family where the parents are disabled.

F. What Is a Disability?

The issue revolves around which traits
are considered to be disabilities and which traits are considered to be
variations of “normal” (or more aptly, “typical”). There is a line beyond which
normative halacha would consider a trait to be
a disability worthy of avoidance while considering another undesirable trait
which is less “severe” to be insignificant.

The question of defining a disability
is a sensitive one, but it need not be. The term disability is a descriptive
term, not a value judgment. In the most literal sense, one who lacks the
ability “to perform some or all of the tasks of daily life” or a “medically
diagnosed condition that makes it difficult to engage in the activities of
daily life” is the dictionary definition of disability.[22]
One may have other wonderful traits and coping mechanisms that make up for the
disability, but that does not remove the obstacles inherent in the disability.

Some disabilities are relative, such as
height. The Americans with Disabilities Act (ADA) recognizes that in a world
built for those five to six feet tall, being of very short stature is a
disability.[23] That
is why the law particularly includes dwarfism. “Little People of America,” a nonprofit organization that provides support and
information to people of short stature and their families, recognizes
this reality:

Certainly a number of short-statured
people could be considered disabled as a result of conditions, mainly
orthopedic, related to their type of dwarfism. In addition, access issues and
problems exist even for healthy LPs. Consider, for example, the simple fact
that most achondroplastic adults cannot reach an automated teller machine.
Dwarfism is a recognized condition under the Americans with Disabilities Act.[24]

Other disabilities are more objective,
such as blindness or deafness, both of which are also included in the ADA. If no one else could hear, being deaf would not be a disability. But in a world where
others can hear, being deaf is a disability. At least in the workplace, society
attempts to help level the playing field by enacting laws such as the Americans
with Disabilities Act. While many people with disabilities are able to overcome
their limitations, many still need significant extra help.

G. Choosing Not to Choose

While it is clear that Jewish law does
not sanction the usage of assisted reproduction to deliberately create children
with preventable disabilities, such a desire is unlikely to become a common
scenario. The ability to perform PGD raises a far more complex problem. Take,
for example, the case of married dwarves who wish to have viable children. The
most common type of dwarfism is achondroplasia, a condition that usually allows
for a normal life expectancy and normal intelligence. The main features of the
condition are disproportionate short stature and a high frequency of orthopedic
abnormalities, which may cause medical problems such as spinal stenosis and
hydrocephalus. The inheritance of two genes for achondroplasia (homozygous
achondroplasia) is a lethal condition. If a child inherits one gene for the
condition, he will be a dwarf. Therefore, if two dwarves with heterozygous
achondroplasia marry, there is a 25% chance of having a child with a lethal
condition, a 50% chance of having a child who is a dwarf, and a 25% chance of
having a child of normal stature. Obviously, dwarf parents would like to avoid
having children with a lethal condition, so IVF with PGD is an excellent (and
halachically sanctioned) option. However, once the pre-embryos homozygous for
achondroplasia are removed, which pre-embryos should be implanted – the dwarves
or the normal stature ones? That is, once a dwarf couple is doing IVF and PGD
for the permitted purpose of avoiding the lethal disease, a decision must be
made regarding which of the remaining pre-embryos to implant.

This question is well framed by the
response of “Little People of America”
(LPA) to an inquiry as to whether it has a policy on choosing a dwarf child as
part of the IVF procedure. The well reasoned response by LPA’s medical resource
director, a genetic counselor, speaks to the more difficult set of questions
that can arise during IVF:

LPA has no policy on PGD. But I
guarantee you that the position statement would be that dwarf parents be able
to implant whichever embryos looked best suited for implantation, regardless of
whether they are heterozygous for dwarfism or unaffected. I know of no parents
who would make a choice involving termination or not using an embryo so
as to only have a dwarf child. They just don’t want to be told that their
only option is an average-stature child. . . . We just want the opportunity to
not have the double dominant. The issue is that some doctors involved in PGD
want to tell us that we can’t have children like ourselves. Even when using
technology, we would like that option to continue to be possible, not
guaranteed.[25]

It is clear that the major poskim
permit IVF and PGD only in order to avoid having a child with a disease or
abnormality, and it is very unlikely that any posek would permit these
procedures in order to specifically create a child with a disability. But once
IVF/PGD is being performed for infertility or to legitimately prevent lethal
disease (such as homozygous achondroplasia) or severe disability, must we
actively prevent the implantation of other pre-embryos with less severe
disabilities, such as dwarfism or deafness?

H. Is There a Prohibition of Choosing a Disabled
Child Once IVF Is Being Performed?

When the question posed is choosing
between implanting a pre-embryo with a lethal disease or one with a normal
genotype, the decision is straightforward: we opt for the healthy child. In
reality, this simple dichotomy is not always the case. If the condition that is
discovered by PGD is not life-threatening, but only significantly limiting, the
prospective parents, who may be disabled themselves, are faced with the
question of whether to implant an embryo with a disabling genetic disorder. Do
the would-be parents have any moral responsibility to their yet unborn children
that might compel them to avoid implanting the affected pre-embryos?

Rabbi Dovid Cohen argues that the
parents do indeed have such an obligation.[26] He
postulates that the prohibition of causing pain to another Jew includes a not
yet conceived fetus. Just as one may not take an action that will cause “tzaar”
to another person, one may not perform an action that will create a
child who will suffer.[27] He
uses this concept to forbid a single woman from becoming impregnated by IVF via
a donor since this would necessarily create a “fatherless” child, who will be
emotionally pained and embarrassed by the circumstances of his birth.[28]

The novel approach of Rabbi Cohen does
not imply a lesser value to the life of a disabled child. Judaism approaches
the birth of a child as a blessing and every life is valuable and treasured.
Jewish law does not have the secular legal concept of wrongful life, which is accepted
in many legal systems around the world.[29] While
Judaism recognizes no such right on the part of the child, it does posit an
obligation on the part of the responsible party to choose wisely for the not
yet implanted pre-embryo.

There is a general Jewish legal ethic
that from the perspective of the parent, there is a preference, or possibly an
obligation, not to take an action that will likely create a child that is
disabled. This is clear from the Talmudic dictum that specifically advises
against any marriage that will likely create genetically inherited diseases in
offspring. The Talmud (Yevamot 64b) states that “. . . a man should not marry a woman
from a family of epileptics or from a family of lepers.”[30]
The presumption is that in either case, by marrying into such a family, he
would endanger the health of his prospective offspring.[31]
In practice, halacha applies this rule to any
hereditary or contagious disease.[32]
Elsewhere in the Talmud, we see that there is concern for purposefully creating
children that are significantly different from the average in physical
appearance, including the admonition that “a very (abnormally) tall man should
not marry a very tall woman lest their offspring be abnormally tall. A dwarf
should not marry a dwarf, lest their offspring be a dwarf of the smallest
size.”[33]

These Talmudic principles are applied
by contemporary poskim to carriers of genetic defects. Rabbi Moshe
Feinstein, universally considered among the greatest 20th-century
experts in Jewish law, favored testing young men and women for Tay-Sachs
disease when they reach marriageable age.[34]
Carriers are then discouraged from marrying each other and thereby avoid the
possibility of producing offspring with the deadly disease.

Similarly, while the Talmud and some later
halachicauthorities considered it praiseworthy to marry one’s niece
(i.e., a sister’s daughter), contemporary halachic authorities rule that one
should not marry close relatives for fear of hereditary abnormalities in the
subsequent children.[35] Referencing
contemporary halachic authorities,[36] Rabbi
Prof. Avraham Steinberg explains that the endangerment of one’s offspring is
subsumed in the binding Jewish legal axiom that rules that “regarding danger to
life, [we] are more stringent than [regarding] ritual regulations, and one
should avoid such danger.”[37]

It is crucial to stress that Judaism
demands respect for every person, regardless of their physical attributes or
disabilities. However, it is clear from the Talmud and later Rabbinic writings
that Jewish law demands that we not voluntarily compromise our children’s
health and well-being for our own agendas.

I. Where Is the Line?

Nevertheless, determining which traits qualify as sufficiently limiting
to merit active avoidance requires thought. While some traits may be relatively
desirable (good visual acuity) or undesirable (male pattern baldness), they are
not taken into account in choosing pre-embryos for implantation. Such traits
are not considered important enough to warrant having a role in implantation
decision-making.

Even when IVF and PGD are being
performed for a particular indication, such as avoidance of Tay-Sachs disease,
we do not give the parents a print out of the genetic code of each pre-embryo
and ask the parents if we should implant the ones that are taller, or smarter,
or more athletic, nor do we usually ask which sex child the parents would like.[38]
But some genetic traits are more ethically vexing. All things being equal, does
the pre-embryo Tay-Sachs carrier state play a role in choosing which pre-embryo
to implant? Should the parents deliberately choose the homozygous normals, even
if they are not of the highest grade from an implantation standpoint, to avoid
issues of Tay-Sachs disease in future generations?[39]
Alternatively, perhaps the parents should choose not to take into account which
pre-embryos are heterozygous for Tay-Sachs (since children with the Tay-Sachs
trait would be normal), but only take into account which pre-embryos have the
best chance of creating a viable pregnancy. The latter course is more likely to
yield a successful pregnancy, a concern particularly important to an otherwise
infertile couple. In practice, the carrier status of a pre-embryo would not be
considered significant enough by Jewish law to merit being excluded from
implantation.[40]

The genetic counselor from Little
People of America argues that dwarf couples should be permitted to do the same
thing as Tay-Sachs carrier couples: not to choose the pre-embryos that will be
dwarves, but rather not to choose at all beyond removing the lethal homozygous
pre-embryos. They merely want the pre-embryos to be graded based on likely
viability of the pregnancy and they will accept whichever child results,
whether dwarf or normal stature. Their objection is to being told that they have
to choose the normal stature child over a dwarf child, regardless of the likely
outcome of the pregnancy (a choice that a Tay-Sachs carrier couple may also
find problematic if being required to choose the homozygous unaffected
pre-embryos would reduce the chances of a successful pregnancy). Many
dwarves do not consider dwarfism to be sufficiently problematic to bar
implantation of a pre-embryo, just as the general populace does not consider
poor eyesight, poor hearing, mildly decreased height, etc. as valid criteria
for not implanting a pre-embryo. Is there a halachic imperative to choose the
typical child over the non-fatally disabled child when performing PGD?

J. Halachic and Hashkafic Justifications for Avoiding
Disabilities

The issue is not relative value of
life. From the point of view of Torahhashkafa, one child is no more
valuable than another.[41] The
real issue is whether the Torah requires that a parent attempt to make the life
of his child as trouble free as possible.

The beginning of the book of Samuel
describes the angst of Chana, who had been childless for many years. One year
while visiting the Tabernacle during a festival, she formulated a heartfelt
prayer requesting of G-d that she be blessed with a child.[42]
In her prayer (I Samuel 1:11), Chana requests “zera anashim,” literally translated as “seed of
men.” The Talmud (Berachot 31b)entertains four possible interpretations of this phrase, the last one
being that Chana requested a child who would be typical:

Rashi there explains that Chana did not
wish her son to be out of the ordinary so as not to “provoke amazement in the
eyes of those around him.” There is an unequivocal message that parents should
desire that their children “fit in” with the rest of society and should not
have to feel the pain of being “different.”

The “shehecheyanu” blessing is recited upon reaching any religiously significant
milestone that brings joy. In his glosses to the Shulchan Aruch’sdiscussion of shehecheyanu (Orach Chaim 225:2), Rabbi Moshe
Isserles adds that there is a special blessing to be recited at the time of a
son’s bar mitzva. The text of the blessing is: “Blessed is He Who has relieved
me of the punishment associated with this one.” This might appear to be an
unusual way to display joy, but according to Rabbi Meir Levush (cited
in Magen Avraham, ibid. 5),
the reason for the blessing is to signify the father’s relief that he will no
longer be responsible for causing punishment and suffering to his son by his
own misdeeds, “for until now, the son was punished for the transgressions of
the father.”

We see from the prayer of Chana and the beracha
recited at the time ofbar mitzva that the appropriate emotion for the
parent is to wish normalcy on his child and to loathe being the source of their
child’s suffering. Certainly to choose a disability for the child is
unthinkable, but even to choose not to prevent a disability in a child which
will cause suffering or hardship is also not the Torah approach. It is the
height of selfishness to desire a disabled child for one’s own benefit. As King
Solomon teaches (Proverbs 3:17), “d’racheha darchei noam – the ways of the Torah are
pleasantness,” and “it is not darchei noam, it is not a pleasant way, to
have your child suffer” from a preventable, disabling genetic condition.[43]

So if all pre-embryos in a given IVF cycle have an
equal chance of producing a successful pregnancy, the proper approach would be
to choose those pre-embryos that would produce a child that would not have
preventable significant suffering.[44]

K. Choosing Infertility over Possible Disability

Sometimes the choice is not so easy.
Potentially, it may not be possible to have a child and avoid a high likelihood
or certainty of the child having a significant disability. Deliberately sterile
marriage is not permitted in Jewish law. Before the advent of the new
reproductive technologies such as IVF with PGD, couples were still required to
fulfill the mitzva of procreation, even when
there was a high risk of a sick or disabled child.

This principle is illustrated by the
Talmud (Berachot
10a) with
respect to an event recorded in II Kings 20:1 and Isaiah
38:1. King Hezekiah became deathly ill and the prophet Isaiah came to
visit him, warning him that he would soon die and lose his place in the World
to Come:

[Hezekiah] said to [Isaiah]: What is the reason
for all this? [Isaiah] said to him: It is because you did not engage in [the
mitzva of] procreation. [Hezekiah] said to him: That was because I saw with ruach
hakodesh (Divine inspiration) that immoral children would come forth from
me! [Isaiah] said to him: What concern are the hidden things of Hashem to you?
What you are commanded to do [by Hashem], you are required to do; and what is
good before Hashem, He will do!

While King
Hezekiah had believed it better to remain celibate than to bring evil children
into the world, the
Talmud teaches that the deliberate refusal to have children, even if the
offspring will inevitably be limited or even immoral, as punishable by
premature death and the loss of a place in the next world. Obviously, one who
is unable to have children is exempt from the mitzva of procreation.[45] In fact, one is not required or
expected to utilize extraordinary measures, such as IVF, to produce children.[46] Nevertheless, one is still required
to attempt all natural means at one’s disposal to marry and have children, even
if the children might be born with disabilities.

One might therefore infer
that disability is not an important criterion in Jewish “family planning” when
the parents have a known genetic defect. This would be a misinterpretation of
the Jewish approach to childbearing. The juxtaposition of two responsa of Rabbi
Moshe Feinstein illustrates the dual nature of the obligation to procreate: the
obligation to marry and have children on the one hand and the expectation that
parents try to avoid genetic defects in their offspring on the other.

In 1973, a few years after the introduction of Tay-Sachs carrier screening programs, Rabbi Feinstein was
asked if one should test for Tay-Sachs carrier status before marriage. He wrote
(Responsa
Igrot Moshe, Even HaEzerIV:10):

I have been asked my opinion regarding several questions: (1) Is
it proper for a boy or girl to endeavor to find out their carrier status? (2)
If it is desirable, should the test be done during youth or only once one
reaches the age of marriage? (3) Should the testing be done publicly or
privately?

I looked into
these questions and my humble opinion is that even though only a small minority
of children are born with this disease, and it is appropriate to apply the verse “You
must act wholeheartedly with the Lord your G-d”(Deuteronomy18:13) and as Rashi explains it, “walk with Him wholeheartedly and
anticipate His support, and do not delve into the future”; nevertheless, since
this information can be discovered so easily, it is possible to say that if one
does not test himself, it is as if he is closing his eyes to seeing that which
it is possible to [easily] see. And since that if, G-d forbid, this were to
happen (to have a Tay-Sachs baby), it would cause tremendous suffering for the
parents of the child, it is appropriate for one who is ready to get married to
test himself. And thus it is proper to publicize the test in newspapers and
through other avenues that would inform the public that there is a test like
this.

Rabbi Feinstein supported utilizing
technology to proactively avoid creating children with severe genetic defects.
His only implied reservation is whether the infrequency of Tay-Sachs carrier
status (and therefore the rarity of children afflicted with Tay-Sachs) merits
active intervention such as genetic screening to prevent the birth of Tay-Sachs
babies.

However, when asked what the case would
be if the trait was dominant and therefore the possibility of severely affected
offspring could not be prevented, Rabbi Feinstein was definitive that the
obligation of procreation is paramount.[47] In
dealing with case of an unmarried 25-year-old man with a severe case of Marfan
syndrome,[48] Rabbi
Feinstein wrote (Responsa Igrot Moshe, Choshen Mishpat
II:73b):

If he marries a normal woman, half their children may be expected
to inherit the disease. Is he forbidden to marry a woman who can
bear children, or, on the contrary, is he obligated to fulfill the obligation
of procreation?

It is, in my opinion, obvious that if he can find a woman who
knows his condition and is willing to marry him (because he must inform her
before marriage so that the marriage ceremony not be under false pretences,
[which would annul the marriage] and, regardless of this, it is prohibited to
commit fraud in marriage to the same extent as in business, and maybe even more
so), he is permitted and obligated to marry her to fulfill the mitzva of procreation. Behold, it is possible that he
will have healthy children, and he should pray to G-d to grant him upright and
healthy children. It is possible that all his children will be healthy, since
[the statistic that] half the children are afflicted represents only a
probability and therefore this does not represent [praying for] a miracle.

And even if
some of his children will have the disease, he will still fulfill his
obligation, since they [are viable children who] can fulfill the obligation of
inhabiting the world. . . .[49]

Rabbi Feinstein
concludes by stating that “Only if all fertile women refuse him, then it is
beyond his control, and he is exempt from the obligation of procreation. [In
such a case,] he should then marry a sterile woman because of the obligation to
marry.”

It is apparent from the approach of Rabbi Feinstein that while
prevention of abnormalities is desired and expected if possible, it does not
trump the obligation of procreation.[50]
It would follow from the two rulings of Rabbi Feinstein that one should avoid
marrying a spouse where the union has a high probability of producing children
with significant genetic abnormalities (such as two Tay-Sachs carriers or the
Talmud’s advice against two dwarves marrying at a time when there was no way to
avoid the outcome of dwarf or lethally affected children).

However, if avoidance of defects is not possible within the
realm of normal behavior, so long as the marriage will produce viable
offspring, procreation is required. For this reason, there is no obligation on
the part of two married dwarves to avoid having children naturally even if the
probability is that 75% of the children will be dwarves or non-viable.

The rulings of Rabbi
Feinstein apply to natural, unaided procreation, where the avoidance of the
possible creation of a disabled child is not possible. But if the couple does
choose to utilize IVF with PGD (an endeavor into which they are not required to
enter), then the scenario changes. The ability to avoid children with a lethal
homozygous genome and the ability to choose children unaffected by dwarfism are
now within their control. In such a case, the preponderance of halachic
evidence would indicate that if there is a choice, the couple should choose to
implant the unaffected pre-embryos if they will likely lead to a viable
pregnancy. This analysis fits well with
Rabbi Cohen’s psak, which would bar the deliberate creation of a
disabled child by IVF but allow married couples who run the risk of having
disabled children to reproduce naturally.

While one may argue that such a choice is not absolutely
required,[51]
the reasoning of Rabbi Dovid Cohen might necessitate agreeing to choose the
unaffected pre-embryo as a prerequisite for performing IVF in the first place.
All poskim would agree that the sole reason why IVF is permitted,
considering the halachic barriers, is to fulfill some part of the mitzva of
procreation. However, all would also agree that one may not utilize the
optional process of IVF if by doing so one transgresses some other prohibition.
The logic is similar to that of Rabbi Moshe Feinstein, who forbids a kohen
from becoming a doctor if it requires touching or being in an enclosure with a
corpse.[52]
Rabbi Cohen argues that there is no permission to undertake the optional act of
IVF if by doing so one intends to transgress the prohibition of causing pain to
a fellow Jew. If the choice is between infertility or a priori knowledge
that the use of assisted reproduction will result in the definite creation of a
disabled child, Rabbi Cohen rules that one must remain childless.

L. A Last Dilemma: Infertility versus
Disability

However, in almost every case, the knowledge that all
available pre-embryos will result in disabled children does not arise until after
the IVF procedure has commenced and the halachic barriers have been surmounted.
Even if one accepts the logic of Rabbi Cohen that one may not utilize IVF for
the purpose of creating a disabled child from the outset, once the IVF process
is initiated, it is not necessarily the case that if all available pre-embryos
will grow into disabled children, that one may not implant any of them. Perhaps
at that point, the pre-embryos are treated similarly to the potential offspring
of natural conception. The choice whether to implant in such a case would
likely depend on the particular condition, the spectrum of disabilities that it
might cause, and the probability that the child would develop severe
manifestations of the condition. Rabbi Cohen applies his ruling even in this
case, barring implantation of a pre-embryo that will develop into a disabled
child. Nevertheless, the degree of disability required to bar implantation
remains a subjective one, even for Rabbi Cohen.

In every case, the choice whether to implant a potentially disabled
embryo is an emotional one. The already born individual with a particular
genetically-based disability sees the choice not to implant a pre-embryo with
the same genetic defect in favor of a “normal” pre-embryo as questioning the
value of his own existence, an existence which the disabled individual
rightfully considers of infinite value. He may approach the issue as if the
decision to implant the “normal” pre-embryo implies that those doing the
implanting have judged that it would have been better had the living disabled
person never have been born. The already existing person approaches the implications
of PGD from a personal “after the fact” perspective, possibly feeling that a
decision not to implant a pre-embryo with the same defect that he possess is a
rejection of his personal worth.

The third party performing IVF-PGD, however, sees the decision as a
choice between alternatives and should opt for the one that will likely create
the best outcome, that being a child without a disability. He or she is
choosing between two not yet extant humans and is determining which one should
become a tangible human being. The parents undergoing IVF enter the
decision-making process from an a priori perspective, grappling with the
issue of which pre-embryos to implant.

But, when the only currently extant pre-embryos will have a severe
disability, the choice is to implant or attempt another round of IVF which may
not be feasible. While recognizing that the decision not to implant may appear
to some to make the bold statement that it is intrinsically better not to have
people with certain disabilities, we must recognize that this simply is not the
case. The world is better for having all of the people that Hashem has chosen
to create, but the Torah-observant Jew recognizes that the corpus of Jewish law
and tradition would suggest that a parent not create a child who will suffer if
it can be avoided.

M. The Conundrum of Non-Existence

There is a fundamental existential question underlying the whole
discussion of choosing a disability as part of an IVF procedure, whether
directly by opting to implant an affected embryo or indirectly by not
preventing the implantation of an affected embryo. If only two options are
available, is it better to be born with a disability or to have never been born
if one will be affected by a severe disability? While it may seem that we
cannot have the perspective necessary to answer such a question, the concept
underlying this difficulty was the basis of a debate between the great Tannaim.
The Talmud (Eiruvin 13b) reports:

For two and a half
years, the School of Shammai and the School of Hillel debated. These said, “It
is better for man not to have been created than to have been created”; and
these said, “It is better for man to have been created than not to have been
created.” They voted and concluded that it would have been better for man not to have been created,
but now that he has been created, let him investigate his deeds.

This cryptic passage lies at the heart of the question of whether
parents should create children with disabilities. The Talmud teaches that one
must accept life as it is. For each individual, his life is of the utmost value
and must be cherished, regardless of what obstacles lay before him. It lies
within the soul of each person to make the most of their gifts and their lives.
Some people with no apparent limitations make nothing of their life. Others,
with apparently insurmountable obstacles achieve great things.[53]

However, it is an inescapable truth that some obstacles are not a
priori welcome. The conundrum is that were an individual never to have been
created, he could not contemplate whether it would be better to have been
created. A person necessarily lacks a point of reference from which to make the
determination of whether it is better to have been created, since the
alternative cannot be conceptualized. However, while the Talmudic discussion
takes place between men who have already been created, because the decision to
create them was made by G-d, the unavoidable conclusion is that from G-d’s
perspective, it must have been better to have created man than not.

The Talmud’s conclusion that it would have been better for man not to
have been created is from the perspective of an already created being. From our
viewpoint, given the trials and tribulations of life, it may appear to us that
it would have been better never to have been put in this world. But since we
are here, we must make the best of it, and must strive for greatness, because
that is what G-d, the ultimate arbiter of value, has decreed.

But, when the decision to create a person is not a result of the biblical
mandate to procreate, but is the optional decision of a couple to create a
child where known disabilities will ensue, we cannot necessarily claim that it
is better to be created than not. The Torah has commanded us to avoid causing
avoidable pain to others and the reality that Hashem chooses to create children
with disabilities does not absolve us of our own Torah obligations. The
acceptance of life as Hashem creates it does not justify purposeful creation of
humans with severe disabilities accept when mandated by the Torah.

Rabbi Cohen argues that when there is a high likelihood of disability
arising as part of the IVF procedure, the parents must utilize PGD to ensure
the implantation of an unaffected embryo. For a couple who have a high
likelihood of producing a disabled child by normal conception, Rabbi Cohen
recommends utilizing IVF with PGD to forestall that possibility. Of course, no
technology can eliminate the risk of producing a disabled child, but Rabbi
Cohen believes that one is required to do one’s best to avoid such an outcome.

So when we apply our “conundrum of non-existence” to pre-implantation
diagnosis, we see that the roles change. We must now perform the role of G-d as
He has instructed us through theTorah. We must take the best interests
of the would-be child into account and decide under which conditions the
potential child should not be born and duly avoid creating such a child. Just
as G-d’s decision is necessarily made as a third party, so must our decision be
made the same way, since there is no way to consult with the yet unformed
child. Some of these conditions are accepted as self-evident, such as Tay-Sachs
disease. Regarding some conditions, there will likely be no consensus.

The only objective criteria that we can and must demand is that the
decision be based on what is best for the potential child and not what is best
for the prospective parents. Self-interest and ego on the part of the parents
must not be used as a criterion in making such a crucial life and death
decision. If we apply this rule with intellectual honesty, a consensus is much
more likely to be obtained.

N. Limitations on the Ability to Choose

Despite theTorah-based mandate to actively pursue normalcy for
our children, the ability to prevent a disabled child from entering the world
is limited by our personal Torah obligations. The commandment to procreate
supersedes many other decision-making factors involved in PGD. That is, our
ability to evaluate whether it would be better for a child not to be born only comes
into play if we pursue technological assistance to fulfill the mitzva of procreation. Otherwise, the decision is
not in our hands.

It is important that we not devalue any
person based on their outward characteristics. However, Judaism requires that
we make an effort to bring normality to our children. In our attempt to grant
respect to everyone, we must avoid harming others. It is not disrespectful to
recognize the equality of those born with limitations, yet recognize that it
would be better not to be limited. Using in vitro fertilization to deliberately
create children with disabilities is a fundamental misuse of modern
reproductive technologies and an abuse of the Torah mandate to manipulate the
world for the good of mankind.

To specifically choose to have a deaf,
dwarf, or otherwise disabled child is to purposefully create unnecessary
serious obstacles for the child. While many disabled people overcome their
limitations and pursue lives virtually indistinguishable from their neighbors,
it is seldom without great effort.

The Mishna(Pirkei
Avot 5:26) teaches that the
gain in life is proportional to the pain. However, the Torah also teaches that
one may not deliberately make life more difficult for himself[54]
or another by placing a physical or emotional stumbling block before someone
who is challenged in a given area.[55]
Despite the natural desire of a parent to have children that resemble
themselves, no person has the right to place serious obstacles before their
children in order to satisfy their own self-interest. While we respect all
people equally, whether healthy or ill, we must not lose sight of the Torah’s
mandate to heal. So too, while we value and love all children equally, we must
not lose sight of our ultimate goal of removing all possible physical and
emotional limitations from our children and we must not give up on our desire
to make the lives of our children the best that they can be.

While the particular applications of
the new reproductive technologies, particularly PGD, will require specific
rulings from great poskim, taking into account the multiple discussions
in from the Tanach to the present, it would seem that the Torah commands that
we proactively attempt to create children who will not have severe handicaps.
Having a child through the new reproductive technologies is not a religious
duty and the preponderance of halachic sources seem to indicate that one should
not pursue such technology at the expense of creating a child who will suffer.

When all is said and done, if we wish to have the
“best” children possible, nothing has really changed. We must rely upon the
same factors as our ancestors – choosing the right mate, good parenting skills,
and a heavy dose of siyata diShmaya (Divine help).[56]

[1] For a discussion of the checkered history of eugenics,
see Richard A. Soloway, “The ‘Perfect Contraceptive’: Eugenics and Birth
Control Research in Britain and America in the Interwar Years,” Journal of
Contemporary History 30 (1995): 637–664. See also the classic work by Mark
A. Haller, Eugenics: Hereditarian Attitudes in American Thought (New Brunswick,
NJ: Rutgers University Press, 1965).

[3] The AP story by Lindsey Tanner, originally posted on
December 21, 2006, was utilized by multiple news outlets, including MSNBC
(http://www.msnbc.msn.com/id/16299656, “‘Designer’ Babies With Made-To-Order
Defects?”); CNN

[4] S. Matthew Liao, Julian Savulescu, and Mark Sheehan,
“The Ashley Treatment: Best Interests, Convenience, and Parental
Decision-Making,” Hastings Center Report, March–April
2007, pp. 16–17. As explained by the authors, static encephalopathy is a
“severe brain impairment that leaves her unable to walk, talk, eat, sit up, or
roll over. According to her doctors, Ashley has reached, and will remain at,
the developmental level of a three-month-old.” After pressure from a
disabilities rights group, Seattle Children’s Hospital administrators admitted
that they had violated state law by failing to consult a judge before removing
Ashley’s uterus.

[6] The account of Rachel’s infertility in Genesis 30:1
describes the jealousy and lack of fulfillment experienced by Rachel due to her
lack of children. She demands of Jacob: “Give me children! If not, let me die!”
(A. Kaplan, Living Torah, Brooklyn, NY: Maznaim Publishing Corp., 1981), or
alternatively, “Give me children, for if not, I am dead!”

[12] Rabbi Prof. Steinberg refers to the reality that in
many countries, the state has taken an interest in helping to defray the
costs of reproductive technologies for infertile couples. In some parts of the United States, health insurance companies are mandated by law to include infertility
treatment among covered benefits. Personal communication with Rabbi Professor
Avraham Steinberg, February 7, 2007.

[13] Those poskim forbidding IVF fall into two main
categories: Some authorities object to IVF due to considerations unrelated to
the actual procedure itself. Others, such as Rabbi Eliezer Yehuda Waldenberg (Responsa
Tzitz Eliezer 15:45; "הפריה
במבחנה דיון
רפואי
והלכתי"Assia, vol. 5, (Jerusalem,
Israel, Schlesinger Institute, 1986, pp. 84–92) and Rabbi Moshe Sternbach (BiShevilei
HaRefua 8:29–36), object to IVF due to concerns involving emission of seed
in vain, the fact that it is usually not performed for male infertility, their
opinion that paternity is not established through IVF, and the fear of the
introduction of sperm or eggs from someone other than the married couple.
However, these objections do not concern IVF conceptually but represent
barriers that would prevent one from reaching the point where these poskim
would permit IVF. Authorities such as Rabbi Ovadia Yosef (Responsa Yabia
Omer 8, Even HaEzer 21), Rabbi Avigdor Nebenzahl (“Notes on the Examination
of the Pre-embryo,” "הפריה
במבחנה–הערות"Assia vol.
5, 1986, pp. 92–93), and Rabbi Yosef Sholom Elyashiv (cited in Prof. Avraham S.
Avraham, Nishmat Avraham (second expanded edition), vol. 3, Even
HaEzer,p. 27) all permit IVF from
husband to wife if done under appropriate supervision, but only if there is no
other alternative. Rabbi Prof. Avraham Steinberg points out that in Responsa
Tzitz Eliezer 3:27, Rabbi Waldenberg considers the act of artificial
insemination to be “an abomination and an ugly act which leads to undermining
the family structure.” Encyclopedia of Jewish Medical Ethics (Jerusalem, Israel: Feldheim, 2003), s.v. “Artificial Insemination,” p. 64.

[23] As per the Americans with Disabilities Act, “An individual
is considered to have a ‘disability’ if s/he has a physical or mental
impairment that substantially limits one or more major life activities, has a
record of such an impairment, or is regarded as having such an impairment.”
http://www.jan.wvu.edu/links/ADAq&a.html.

[25] Personal correspondence with Ericka Okenfuss, M.S., January 25, 2007. The text of the question was “Does the LPA have a policy regarding the
use or selection of embryos for in vitro fertilization that carry the genetic
predisposition for dwarfism? That is, do you support the choice of selecting
only embryos that are dwarfs for parents who are dwarves?”

[27]Leviticus 25:17. An
additional source for this idea might be the famous rule of "ואהבת
לרעך כמוך"(Leviticus 19:18) which prohibits any form of abuse, not only
verbal. In addition, seeSeferChasidim
44, which elaborates on this issue.

[28]
It is not the mere lack of a father that is problematic, but the process of
creating a child in such a way that the child is stigmatized.

[29] This legal concept posits that a child who is born
handicapped due to a genetic defect that should have been detected by his
mother’s doctor may be allowed to sue for damages, claiming that he would have
been better off not being born in the first place.

[30] The same restriction applies to a woman marrying into
such a family. See Sefer Chazon Ish, Yoreh Dea 154:2.

[31] Because his wife might bear offspring who will be
epileptics or lepers. Some poskim have forbidden such an act. See Responsa
Chatam Sofer, cited in Otzar HaPoskim, Even HaEzer 2:43; Sefer
Chazon Ish, Nashim 134 in glosses to 64b; Yam Shel Shlom, Yevamot
33).
However, Rabbi Shmuel Kamenetsky, head of the Talmudical Yeshiva of
Philadelphia, told me that the Talmud’s admonition is merely advisory.

[33]Bechorot 45b. The Talmud applies the same
admonition to albinos’ marrying each other. These matches are discouraged, not
because the marriage of the couple is any problem, but because they would be
required to have children to fulfill their mitzva of procreation and might bear
children who share their unusual or undesirable traits. Interestingly, in the
case of dwarves, the Talmud may have been warning about the one-in-four chance
of an achondroplastic couple’s having a gestation incompatible with life
(homozygous achondroplasia).

[35] Support for such marriages is found in Yevamot 62b;
Mishneh Torah, Issurei Bia 2:14; Rama, Shulchan Aruch, Even
HaEzer 2:6. As early as the 12th century, Rabbi Yehuda HaChasid, author of Sefer
Chasidim (477), stated that one should not do so. Several later
authorities, such as Rabbi Yechezkel Landau (Noda BiYehuda, Even
HaEzer 79) and Rabbi Ovadia Yosef (Yabia Omer, vol. 2, Even
HaEzer 7:8–11), concurred.

[38] “Certainly, the use of PGD solely for the purpose of
sex selection, while eminently feasible scientifically, would be considered a
frivolous use of IVF and prohibited by most poskim.” Grazi, Overcoming
Infertility, p. 352. Note that this does not imply that the Torah objects
to utilizing methods that do not interfere with normal marital relations in
order to produce a gender-specific child. The Talmud suggests various ways of
producing boys or girls if a couple desires, but all fall within normal
activities of life, including recommended foods, timing (Berachot 60a, Nidda
25b), and positioning of the bed (Berachot 5b). Nevertheless, some poskim
have permitted gender selection if PGD is being performed for another valid
reason.

[39] “During subsequent days [after fertilization] the
embryos are inspected and graded according to the number of cell divisions that
have occurred and the morphology of the cells within each embryo.” Grazi, Overcoming
Infertility, p. 337.

[42] The Talmud (Berachot 31b) learns many laws of
prayer from Chana’s entreaty.

[43] Rabbi Mordechai I. Willig, “Jewish Gene: Genetic
Screening and the Prevention of Diseases,” Yeshiva University Medical Ethics Society
lecture, March 28, 2006 (available at
http://www.yutorah.org/showShiur.cfm/714313/Rabbi_Mordechai_I._Willig/Jewish_Gene:_Genetic_Screening_and_the_Prevention_of_Diseases).
Rabbi Willig invoked d’racheha darchei noam to explain why it is
inappropriate not to do genetic testing before marriage to prevent Tay-Sachs
babies, but his point is equally valid for preventing any avoidable genetic
abnormality.

Editor’s note: See editor’s note on Rabbi
Asher Weiss, "בענין
גזירת שחירת
סממנים
ולקיחת
ויטמינים
בשבת"
elsewhere in this book, as to the halachic
use of this source throughout the Oral Torah.

[44]Ruling of Rabbi
Dovid Cohen as per personal communication with Rabbi Sholom Kamentsky, May 28, 2007.

[46] “I heard from Hagaon Rabbi Shlomo Zalman Auerbach, z”tl, that there is no obligation whatsoever for an infertile couple to engage in IVF in order to fulfill the mitzva of p’ru ur’vu." Prof. Avraham S Avraham, Nishmat Avraham (second expanded edition), vol. 3, Even HaEzer, p. 27. See also Rabbi Yitzchok Breitowitz, “The Preembryo in Halacha,”

http://www.jlaw.com/Articles/preemb.html: “On one hand, the obligations of p’ru ur’vu and lashevet have never been understood as compelling resort to any type of surgical procedure to achieve procreation. At the same time, most poskimdo consider the offspring produced from IVF as having a familial bond to the biological parents.” Additionally, Rabbi Breitowitz points out that the woman is not required to undergo IVF: “Insofar as ona and lashevet are concerned, these obligations do not require consent to an IVF procedure, nor would [they] require her to complete the procedure once begun.” However, in discussing general halachic issues involved in IVF, Rabbi Prof. Steinberg states that in light of the reasons to permit IVF, “it seems clear that one is allowed, and perhaps even obligated, to use whatever procedures are necessary and allowable to effect procreation.” Encyclopedia of Jewish Medical Ethics, s.v. “In-Vitro Fertilization,” p. 576.

[47]The responsum
was written before in vitro fertilization and pre-implantation genetic
diagnosis were developed. Additionally, Rabbi Feinstein rejected the
possibility of performing an abortion for a genetic defect, ruling that
abortion is in the category of murder. See Responsa Igrot Moshe, Choshen
Mishpat II:69b.

[48] Marfan syndrome is a dominantly inherited disorder
that can cause severe abnormalities of the aorta, eyes, and connective tissues.
The questioner was a student with severe symptoms of the disease and had
already undergone heart surgery and was blind in one eye. It is important to
note that the severity of disease in the offspring may vary.

[49] In Crossroads: Halacha and the Modern World,
vol 2 (Alon Shvut, Israel: Zomet Institute, 1988), p. 61, an English-language
version of what appears to be the same responsum adds two points. After the
line explaining that half of the offspring would be expected to inherit the
disease, the responsum points out: “The disease does not cause mental
impairment or early death. The children may require heart surgery, which itself
poses a certain measure of risk. Physicians recommend that one afflicted with
this disease not have children so as not to pass on the genetic disorder.”
After posing the question of whether the questioner is required to marry, the
responsum continues: “the disease is not especially severe, and he is capable
of bearing children, half of whom will be totally healthy, and half, although
afflicted, will be able to study Torah and fulfill the commandments of G-d. It
is said that President Lincoln was afflicted with this disease and it is
carried by his descendants to this day: nonetheless, he was able to achieve
great things.”

[50]
Rabbi Shlomo Zalman Auerbach questioned “whether one who has a hereditary
disease from which his children will suffer all their lives, or one who has
hemophilia which will be passed on to his male offspring, is permitted to marry
a woman who is unable to have children.” He wrote to Prof. Avraham that “it is
clear to the Igrot Moshe that such a person is obligated to keep the mitzva
[of procreation]; however, in my opinion, this ruling requires further study.” Prof. Avraham S Avraham, Nishmat Avraham
(English), vol. 3, p. 3.

[51] Personal communication with Rabbi Shmuel Kamenetsky, January 31, 2007. The piskei halacha in the final version of this article were
confirmed with Rav Dovid Cohen on October 29, 2007.

[52]Responsa Igrot Moshe, Yoreh Dea III:155. Because there
is no mitzva to become a doctor, despite the mitzvos one may
perform once he has become a physician, Rabbi Feinstein forbids one to transgress
any biblical prohibitions in order to attend medical school.

[54]As we say in the morning prayers:"ויהי
רצון... שתרגילנו
בתורתך,
ודבקנו
במצותיך, ואל
תביאנו לא
לידי חטא, ולא
לידי עברה ועון,
ולא לידי
נסיון, ולא
לידי בזיון,
ואל תשלט בנו
יצר הרע." (And may it be Your will... that
You accustom us to study Your Torah and attach us to Your commandments. Do not
bring us into the power of error, transgression, and sin, or into the power of
challenge, or into the power of scorn. Let not the evil inclination dominate
us).

See
also Bava Batra 57b, which condemns one who “deliberately exposes
himself to a situation in which he might be tempted to sin,” and Sanhedrin
107a, which states that “R’ Yehuda
said in the name of Rav: A person should never bring himself to a test (ed.
note: a situation in which he will be tempted to sin), for David, king of
Israel, brought himself to a test and he stumbled.” See also Avoda Zara
17a–b which makes an exception for the select few who continuously study Torah.

[56] See Nidda 70b-71a which explains that if a man
wishes to have children, in addition to marrying a woman who is spiritually
appropriate for him, he must pray for Divine help. As the Talmud teaches, “. .
.one without the other is not enough.”